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Antibiotics for spontaneous bacterial peritonitis in cirrhotics
K Soares-Weiser1, M Brezis, L Leibovici
1Department of Internal Medicine E, Rabin Medical Center - Beilinson Campus, Petah Tikva, Israel, 41900. ksoares@netvision.net.il
Background:
Spontaneous bacterial peritonitis is mainly a complication of cirrhotic ascites that occurs in the absence of any intra-abdominal, surgically treatable source of infection. Antibiotics have been recommended as the mainstay treatment for spontaneous bacterial peritonitis. However, this recommendation is not based on convincing evidence. It has been proposed that treatment should cover Gram-negative enteric bacteria and Gram-positive cocci, that are responsible for up to 90% of cases.
Objectives:
To evaluate the effectiveness and safety of different types and ways of antibiotic therapy for spontaneous bacterial peritonitis in cirrhotic patients.
Search Strategy:
Electronic searches on the Cochrane Library (Issue 3, 2000), the Cochrane Hepato-Biliary Group Trials Register (March 2000), EMBASE (1980-2000), MEDLINE (1966-2000); scanning the references of all identified studies; contacting the first author of each included trial.
Selection Criteria:
Randomised trials comparing different types of antibiotics for spontaneous bacterial peritonitis in cirrhotic patients.
Data Collection And Analysis:
Data were independently extracted by two reviewers. Relative risks or weighted mean differences, with their 95% confidence intervals were estimated using 'intention-to-treat' analyses.
Main Results:
Nine trials dealing with 684 patients diagnosed with spontaneous bacterial peritonitis were included. No placebo-controlled trial was found. Each of the included trials compared different antibiotics, and no meta-analysis could be performed. We were unable to establish the optimal dose or duration of antibiotic therapy and found no convincing evidence that cefotaxime is more effective than ampicillin-tobramycin or that oral quinolones should be recommended for patients with less severe manifestations of the disease.
Reviewer'S Conclusions:
This review provides no clear evidence for the treatment of cirrhotic patients with spontaneous bacterial peritonitis. Until large, well-conducted, trials provide adequate evidence, treatment must be based on clinical experience.
Insights
This review found no clear evidence for antibiotic treatment of spontaneous bacterial peritonitis (SBP) in cirrhotic patients. Clinical experience should guide treatment until more robust trials are available.
Area of Science:
- Hepatology
- Infectious Diseases
- Clinical Pharmacology
Background:
- Spontaneous bacterial peritonitis (SBP) is a serious complication of cirrhotic ascites.
- Antibiotics are the standard treatment, but evidence supporting their efficacy is limited.
- Common causative agents include Gram-negative enteric bacteria and Gram-positive cocci.
Purpose of the Study:
- To evaluate the effectiveness and safety of various antibiotic therapies for SBP in cirrhotic patients.
- To assess different antibiotic types and administration methods.
Main Methods:
- Systematic review of randomized controlled trials (RCTs).
- Searches conducted across major databases (Cochrane Library, EMBASE, MEDLINE) up to March 2000.
- Data extraction and analysis using intention-to-treat principles.
Main Results:
- Nine RCTs involving 684 patients were included; no placebo-controlled trials were identified.
- No meta-analysis was possible due to trial heterogeneity.
- Insufficient evidence to determine optimal antibiotic dose/duration or superiority of cefotaxime over ampicillin-tobramycin, or oral quinolones for less severe cases.
Conclusions:
- The current evidence base is insufficient to guide SBP treatment in cirrhotic patients.
- Further large, well-designed trials are needed to establish optimal antibiotic strategies.
- Treatment decisions should rely on clinical expertise in the absence of definitive evidence.